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Pulmonary Embolism & DVT

Pulmonary Embolism & DVT. Introduction Pathophysiology Risk Factors Symptoms Lab Findings Radiology Findings Treatment Prevention

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Text of Pulmonary Embolism & DVT. Introduction Pathophysiology Risk Factors Symptoms Lab Findings Radiology...

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  • Pulmonary Embolism & DVT
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  • Introduction Pathophysiology Risk Factors Symptoms Lab Findings Radiology Findings Treatment Prevention
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  • Pathophysiology Dislodgement of a blood clot: Lower Extremities: 65% to 90% Pelvic venous system Renal venous system Upper Extremity Right Heart
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  • Risk Factors for PE and DVT Immobilization Surgery within the last 3 months Stroke History of venous thromboembolism Malignancy Preexisting respiratory disease Chronic Heart Disease Age >60 Surgery requiring >30mins of anesthesia Recent travel (past 2weeks, >4 hours) Varicose veins Superficial vein thrombosis Central VV catheter/port/pacemaker Additional RF in Women: Obesity BMI >/=29 Heavy smoking (>25cigs/day) Hypertension Pregnancy
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  • Wells Criteria Clinical Signs and Symptoms of DVT? (Calf tenderness, swelling >3cm, errythema, pitting edema affected leg only) +3 PE Is #1 Diagnosis, or Equally Likely+3 Heart Rate > 100+1.5 Immobilization at least 3 days, or Surgery in the Previous 4 weeks +1.5 Previous, objectively diagnosed PE or DVT?+1.5 Hemoptysis+1 Malignancy w/ Rx within 6 mo, or palliative?+1 >6: High Risk 2 to 6:Moderate Risk 2 or less:Low Adapted with permission from Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED d-dimer. Thromb Haemost 2000;83:416-20.
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  • P.E. and Malignancy A Presenting sign in: Pancreatic cancer Prostate cancer Late sign in: Breast cancer Lung cancer Uterine cancer Brain cancer
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  • Symptoms of P.E. Dyspnea Pleuritic pain Cough Hemoptysis (blood tinged/streaked/ pure blood)
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  • Signs of P.E. Tachypnea Rales Tachycardia Hypoxia S4 Accentuated pulmonic component of S2 Fever: T 90 associated with adverse clinical outcomes (death, CPR, mechanical vent, pressure support, thrombolysis, embolectomy)
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  • Lab Findings in P.E. (Troponin) Troponin High in 30-50% of pts with mod to large PE Prognostic value if combined pro-NT BNP Trop I >0.07 + NT-proBNP >600 = high 40 day mortality
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  • Lab Findings in P.E. (D-dimer) D-dimer: Degredation product of fibrin >500 is abnormal Sensitivity: High, 95% of PE pts will be positive Specificity: Low Negative Predictive Value: Excellent
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  • S1Q3T3!!!
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  • RAD Right Atrial Enlargement
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  • Lab Findings in P.E. (contd) EKG 2 Most Common finding on EKG: Nonspecific ST-segment and T-wave changes Sinus Tachycardia Historical abnormality suggestive of PE S1Q3T3 Right ventricular strain New incomplete RBBB
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  • Radiologic Findings in P.E.
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  • GOLD STANDARD IN DIAGNOSING PULMONARY EMBOLISM? PULMONARY ANGIOGRAM
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  • Radiology Findings in P.E. (contd) CXR: Normal Atelectasis and/or pulmonary parenchymal abnormality Pleural Effusion Cardiomegally
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  • Whats This??? Hamptons Hump
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  • How About This??? Westermark's Sign: an abrupt tapering of a vessel caused by pulmonary thromboembolic obstruction. This CXR shows enlargement of the left hilum accompanied by left lung hyperlucency, indicating oligemia (Westermark's sign).
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  • Radiology Findings in P.E. (contd) V/Q Scan: Results: High, Intermediate, Low Probability Best if combined with Clinical Probability (PIOPED study): High Clinical Prob + High Prob VQ= 95% likelihood of having a P.E. Low Clinical Prob + Low Prob VQ= 4% likelihood of having a P.E.
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  • Radiology Findings in P.E. (contd) Lower Extremity Ultrasounds If DVT found then treatment is same if patient has a P.E. Disadvantage: If negative, patients with PE may be missed If false positive (3%), unnecessary intervention
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  • Radiology Findings in P.E. (contd) CT Pulmonary Angiography (CT-PA) Widely used Institution dependent Sensitivity (83%) Specificity (96%): if negative, very low likelihood that pt has P.E.
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  • Radiology Findings in P.E. (contd) Pulmonary Angiogram Gold Standard Not easily accessible Radiologist dependent
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  • Radiology Findings in P.E. (contd) Echocardiogram Increased Right Ventricle Size Decreased Right Ventricular Function Tricuspid Regurgitation Rarely: RV thrombus Regional wall motion abnormalities that spare the right ventricle apex (McConnells Sign)
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  • Hypercoagulability Work Up No consensus on who to test Increased likelihood if: Age
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  • Hypercoagulability Work Up Protein C/S deficiency Factor V leiden deficiency AntiThrombin III deficiency Prothrombin 20210 mutation Antiphospholipid antibody High Homocysteine
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  • Most Common Cause of Congenital Hypercoagulablity Protein C resistance d/t Factor V leiden mutation
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  • Treatment of P.E. Respiratory Support: Oxygen, intubation Hemodynamic Support: IVF, vasopressors Anticoagulation Thrombolysis IVC Filter
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  • Anticoagulation Start during resuscitation phase itself If suspicion high, start emperic anticoagulation Evaluate patient for absolute contraindication (i.e.: active bleeding)
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  • Anticoagulation (contd) HEPARIN: Lovenox: if hemodynamically stable, no renal function 1mg/kg BID OR 1.5mg/kg QDay Heparin gtt: if hypotension, renal failure 80units/kg bolus then 18units/kg infusion Goal PTT1.5 to 2.5 times the upper limit of normal COUMADIN: Start once acute anticoagulation achieved Start with 5mg PO qday OR 10mg PO q day If start with 10mg then achieve therapeutic INR 1.4 days sooner Complications and morbidity no different in 5mg or 10mg start Goal INR 2 to 3
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  • Duration of Anticoagulation for DVT or PE* EventDurationStrength of Recommendation First Time event of Reversible cause (surgery/trauma) At least 3 mosA First episode of idiopathic VTE At least 6 mosA Recurrent idiopathic VTE or continuing risk factor (e.g., thrombophilia, cancer) At least 12 mosB Symptomatic isolated calf-vein thrombosis 6 to 12 weeksA *From American College of Chest Physicians
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  • Thrombolysis Considered once P.E. diagnosed If chosen, hold anticoagulation during thrombolysis infusion, then resumed Associated with higher incidence of major hemorrhage Indications: persistent hypotension, severe hypoxemia, large perfusion defecs, right ventricular dysfunction, free floating right ventricular thrombus, paten foramen ovale Activase or streptokinase
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  • IVC Filter Indication: Absolute contraindication to anticoagulation (i.e. active bleeding) Recurrent PE during adequate anticoagulation Complication of anticoagulation (severe bleeding) Also: Pts with poor cardiopulmonary reserve Recurrent P.E. will be fatal Patients who have had embolectomy Prophylaxis against P.E. in select patients (malignancy)
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  • Embolectomy Surgical or catheter Indication: Those who present severe enough to warrant thrombolysis In those where thrombolysis is contraindicated or fails
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  • Questions?